NPIMap

Individual provider Active NPI

Kelly Ann O'Sullivan, M.D.

  • Geriatric Medicine (Family Medicine) Physician
  • Vancouver, WA
National Provider Identifier
1750332474
Registry record updated Mar 17, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Geriatric Medicine (Family Medicine) PhysicianTaxonomy code 207QG0300X
License
4301081068 Issued in MI
Practice address
750 SE Fairwinds Loop
Vancouver, WA 98661-8087
Phone
(231) 838-2765
NPI assigned
May 15, 2006
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Mar 17, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X MD60593078 WA
Geriatric Medicine (Family Medicine) Physician 207QG0300X 4301081068 MI Primary

Addresses

Primary practice location

750 SE Fairwinds Loop
Vancouver, WA 98661-8087

Mailing address

750 SE Fairwinds Loop
Vancouver, WA 98661-8087
Phone (231) 838-2765

Other practice location 1

3400 Main St
Vancouver, WA 98663-2223
Phone (360) 696-5232

Other identifiers 3

IdentifierTypeStateIssuer
N19510003OtherMIMEDICARE INDIV PTAN
5185089MedicaidMI
ON19510OtherMIMEDICARE GROUP PTAN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040525000344 MI Practitioner - Family Practice 1052392305 Reassigns benefits to 3 organizations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
4301081068MIMDGeriatric Medicine (Family Medicine) Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Saint Mary's Health Services CurrentSince Sep 19, 2022 Accepting new patients
Advantage Health Saint Mary's Medical Group CurrentSince Nov 21, 2023 Accepting new patients
Advantage Health/Saint Mary's Medical Group Current Accepting new patients
Advantage Health Saint Mary's Medical Group CurrentSince Nov 21, 2023 Accepting new patients
Noch Physician Billing Company LLC Family Medicine CurrentSince Jul 1, 2024 Accepting new patients
Saint Mary's Health Services Family Medicine CurrentSince Sep 19, 2022 Accepting new patients
Christian Rest Home Association Past Accepting new patients
Middletown Emergency Physicians, Inc. Past Accepting new patients
Geriatric Physician Staffing, P. C. Geriatric Medicine Past Accepting new patients
Geriatric Physician Staffing PC Family Medicine PastSince Jun 1, 2006 Accepting new patients
Greenville Emergency Physicians, Inc. Past Accepting new patients
Sidney Emergency Physicians, Inc. Past Accepting new patients
Suttons Bay Medical Clinic, PLC Past Accepting new patients

Locations

10047 Crossroad Ct SE
Caledonia, MI 49316
Phone (616) 685-8850

1309 Sheldon Rd
Grand Haven, MI 49417
Phone (616) 842-3600

200 Jefferson Ave SE
Grand Rapids, MI 49503
Phone (616) 685-5000

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Trinity Health at Home - Grand HavenGrand Haven, MI, CCN 231534 Hospice W-2 Managing Employee Sep 1, 2024

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 13

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147651200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1521244800000",
    "number": "1750332474",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "750 SE FAIRWINDS LOOP",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986618087",
            "telephone_number": "231-838-2765"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "750 SE FAIRWINDS LOOP",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986618087",
            "telephone_number": "231-838-2765"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3400 Main St",
            "address_purpose": "LOCATION",
            "city": "Vancouver",
            "state": "WA",
            "postal_code": "986632223",
            "country_code": "US",
            "telephone_number": "360-696-5232",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "O'SULLIVAN",
        "first_name": "KELLY",
        "middle_name": "ANN",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-05-15",
        "last_updated": "2018-03-17",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WA",
            "license": "MD60593078",
            "primary": false
        },
        {
            "code": "207QG0300X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Geriatric Medicine",
            "state": "MI",
            "license": "4301081068",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE INDIV PTAN",
            "identifier": "N19510003",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5185089",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE GROUP PTAN",
            "identifier": "ON19510",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Vancouver, WA

Sources for this page

Verify at the official NPI Registry.